Maternal midterms second half (1/4)

POST-PARTUM HEMORRHAGE (PPH)

Is one of the primary causes of mortality associated with child bearing, which is a major threat during pregnancy, continuing into the postpartum.

Etiology of PPH

The primary causes are the 4 “T’s”: tone (uterine atony), trauma (lacerations or uterine rupture), tissue (retained placenta or clots), and thrombin (coagulation deficiency).

Risk Factors for PPH

Previous history of PPH, known coagulopathy, placenta accreta spectrum, multiple births or gestations, prior uterine surgery, uterine fibroids, and uterine infection.

Clinical Manifestations of PPH

Persistent, excessive vaginal bleeding after delivery, dizziness, blurred vision, feeling faint, tachycardia, decreased hematocrit, pale or clammy skin, and pain/swelling in the vaginal or perineal area.

Diagnostic Evaluation for PPH - Physical Exam

Speculum examination to inspect for lacerations, perineal inspection for external tears or hematoma, and abdominal/uterine palpation to assess uterine tone.

Diagnostic Evaluation for PPH - Laboratory Tests

Complete Blood Count (CBC) to assess blood loss and a Coagulation Profile (PT, aPTT, Fibrinogen, D-dimer) to detect coagulopathies or DIC.

Diagnostic Evaluation for PPH - Imaging

Pelvic Ultrasound to identify retained fragments or inversion; CT Scan or MRI to detect deep hematomas or vascular injury.

Therapeutic Management for PPH - Initial Measures

Perform uterine (fundal/bimanual) massage, empty the bladder, begin fluid resuscitation, and provide blood transfusion if needed.

Therapeutic Management for PPH - Medical Management

First-line: Oxytocin (IM/IV); Tranexamic acid (TXA) within 3 hours to reduce bleeding-related death.

Therapeutic Management for PPH - Non-Pharmacologic

Uterine tamponade (e.g., Bakri balloon or uterine packing) if medications fail.

Therapeutic Management for PPH - Surgical/Procedural

Repair lacerations, remove retained products, uterine artery embolization, compression sutures (B-Lynch), or hysterectomy as a last resort.

Complications of PPH - Short-Term

Hypovolemic shock, Disseminated Intravascular Coagulation (DIC), anemia requiring transfusion, organ failure, sepsis, and pelvic hematoma.

Complications of PPH - Long-Term

Sheehan’s syndrome, Asherman’s syndrome, chronic pelvic pain, loss of fertility, postpartum depression, and venous thromboembolism (VTE).

Prevention of PPH

Early identification of risk factors, routine administration of oxytocin after delivery, controlled cord traction, uterine massage, risk assessment, and prenatal screening/treatment of anemia.

Uterine Atony

Failure of the uterus to contract adequately after delivery of the baby; the most common cause of PPH.

Fundal Massage

The first step in controlling hemorrhage from atony; performed to encourage uterine contraction.

Oxytocin for Atony

A first-line uterotonic drug; action is immediate but short duration (1 hour).

Carboprost Tromethamine (Hemabate)

A prostaglandin F2a derivative used for atony if oxytocin fails; given IM and may be repeated every 15-90 minutes.

Methylergonovine Maleate (Methergine)

An ergot compound used for atony if oxytocin fails; given IM and may be repeated every 2-4 hours.

Misoprostol (Cytotec)

A prostaglandin E1 analogue that may be administered rectally for PPH; a second dose should not be given within 2 hours.

Side Effects of Uterotonics

Diarrhea, nausea, and increased blood pressure; must be used cautiously in women with hypertension.

Additional Measures for Atony

Elevate lower extremities, ensure bladder emptying (catheter if needed), administer oxygen for respiratory distress, and monitor vital signs for trends.

Bimanual Compression

A procedure where one hand is inserted into the vagina while the other pushes on the fundus through the abdomen to compress the uterus.

Blood Replacement for PPH

Often necessary; includes transfusion and iron supplementation to ensure hemoglobin formation.

Hysterectomy for PPH

The surgical removal of the uterus; used as a last resort when all other methods to control bleeding have failed.

Nursing Interventions for PPH

Observe for changes in lochia, monitor temperature for infection, and educate the woman on self-assessment after discharge.

Lacerations

Tears or injuries in the birth canal during delivery; a cause of PPH.

Etiology of Lacerations

Mechanical trauma, rapid fetal descent, instrumental deliveries, improper bearing down, or episiotomy extension.

Clinical Manifestations of Lacerations

Persistent bright red bleeding with a firm uterus, visible tear, pain, tenderness, swelling, hematoma, and dysuria.

Diagnostic Evaluation for Lacerations

Speculum and perineal inspection, digital rectal exam for severe tears, CBC, coagulation profile, and possibly ultrasound/MRI.

Management of Lacerations - Nursing Care

Monitor vital signs and bleeding, maintain asepsis, provide perineal care, encourage hydration/soft diet, apply ice, use sitz baths, and administer analgesics/antibiotics.

Complications of Lacerations - Short Term

Postpartum hemorrhage, hematoma formation, infection, or wound dehiscence.

Complications of Lacerations - Long Term

Scar tissue formation, dyspareunia (painful intercourse), and cervical incompetence.

Prognosis of Lacerations

Excellent with prompt recognition and proper repair.

Prevention of Lacerations

Controlled delivery of fetal head, ensure full cervical dilation before pushing, judicious use of episiotomy, avoid forceful instrumental deliveries, good maternal nutrition, and perineal massage.

Cervical Lacerations

Tears in the cervix, often on the sides near the uterine artery branches.

Key Characteristics of Cervical Lacerations

Source of bleeding is uterine artery branches; bleeding is bright red and continuous; a gush of bleeding occurs despite a firm uterus.

Therapeutic Management of Cervical Lacerations

Repair with sutures; maintain a calm atmosphere; may require regional anesthetic for extensive tears.

Vaginal Lacerations

Tears within the vaginal wall.

Key Characteristics of Vaginal Lacerations

Easily visible upon inspection, tissue is friable making suturing difficult, causes steady bleeding, common along side walls or vaginal vault.

Therapeutic Management of Vaginal Lacerations

Balloon tamponade may be used if suturing fails; an indwelling urinary catheter may be placed after repair.

Perineal Lacerations

Tears in the tissue between the vaginal opening and the anus.

Key Characteristics of Perineal Lacerations

Caused by excessive stretching/pressure during delivery; treated with sutures; can lead to pain, infection, or PPH if not repaired.

1st-Degree Perineal Laceration

Injury to the vaginal epithelium and vulva skin only.

2nd-Degree Perineal Laceration

Injury to the perineal muscles but not the anal sphincter.

3rd-Degree Perineal Laceration

Injury to the perineum involving the anal sphincter complex.

4th-Degree Perineal Laceration

Injury to the perineum involving the anal sphincter complex and anal/rectal mucosa.

Therapeutic Management of Perineal Lacerations

Accurately record the degree of tear; prescribe high-fluid diet and stool softeners; contraindicate rectal temps, enemas, and suppositories for 3rd/4th-degree tears.

Retained Placental Fragments

A condition where the placenta does not detach in its entirety; fragments are left attached to the uterus, preventing full uterine contraction and causing bleeding.

Succenturiate Placenta

A placenta with an accessory lobe; a condition that makes retained placental fragments more likely.

Placenta Accreta

A placenta that abnormally attaches to the myometrium; a condition that can cause retained placental fragments and is associated with previous cesarean birth and in vitro fertilization.

Assessment of Retained Fragments - Large Fragment

Prevents the uterus from contracting, causing heavy bleeding immediately after birth.

Assessment of Retained Fragments - Small Fragment

May not cause immediate bleeding; can cause sudden heavy bleeding around days 6-10 postpartum when the uterus fails to stay contracted.

Etiology of Retained Placenta

Placenta not fully separated, placenta attached too deeply (accreta), placenta trapped after separation, cord pulled too early, weak uterine contractions, or an extra placental lobe left behind.

Clinical Manifestations of Retained Fragments

Fever, heavy vaginal bleeding after birth, foul-smelling vaginal discharge, and passage of many large clots.

Diagnostic Evaluation for Retained Placenta - Timing

Diagnosis considered if placenta not delivered within 30 minutes of active management or 1 hour of physiological management.

Diagnostic Evaluation for Retained Placenta - Inspection

Checking the expelled placenta after birth to ensure it is complete.

Diagnostic Evaluation for Retained Placenta - Imaging

Ultrasound scan to check for retained tissue in the uterus if symptoms appear days or weeks after birth.

Management of Retained Placenta - Immediate Measures

Ensure bladder is empty, gentle controlled cord traction, change maternal position, encourage uterine contraction via breastfeeding or nipple stimulation.

Management of Retained Placenta - Surgical

Manual removal of the placenta under anaesthesia if other measures fail; antibiotics may be prescribed after removal.

Therapeutic Management for Retained Fragments

Removal by dilatation and curettage (D&C); if not removable, methotrexate may be used to destroy the tissue.

Patient Education for Retained Fragments

Monitor lochia color and report any change from lochia serosa/alba back to rubra, indicating returning bleeding.

Complications of Retained Placental Fragments

Uterine infection (endometritis) and postpartum haemorrhage from ineffective uterine contraction.

Prevention of Retained Placenta

Ensure empty bladder during third stage, use active management of third stage (uterotonic, controlled cord traction, uterine massage), inspect placenta for completeness, and monitor delivery time.

Uterine Inversion

A condition where the uterus turns inside out with the birth of the fetus or delivery of the placenta.

Classification of Uterine Inversion - Incomplete

The fundus is inside the uterus but has not passed through the cervix.

Classification of Uterine Inversion - Complete

The fundus has passed through the cervix into the vagina.

Classification of Uterine Inversion - Prolapsed

The fundus protrudes outside the vaginal opening.

Etiology of Uterine Inversion

Pulling the umbilical cord too strongly with attached placenta, applying fundal pressure before uterus contracts, or a fundally-attached placenta pulling the uterus inward.

Clinical Manifestations of Uterine Inversion

Sudden gush of vaginal blood, fundus not palpable abdominally, a visible mass at the vaginal opening, and signs of shock (low BP, dizziness, pallor, sweating).

Diagnostic Evaluation for Uterine Inversion

Primarily clinical; absence of uterine fundus on abdominal exam, visible/palpable inverted uterus in vagina, signs of shock and continuous bleeding.

Therapeutic Management for Uterine Inversion - Immediate Actions

Do not remove attached placenta, stop oxytocin, start IV fluids, give oxygen, prepare for CPR.

Therapeutic Management for Uterine Inversion - Uterine Relaxation

Administer general anesthesia, nitroglycerin, or tocolytics to relax the uterus.

Therapeutic Management for Uterine Inversion - Manual Replacement

The physician or midwife pushes the uterine fundus back into its correct anatomical position.

Therapeutic Management for Uterine Inversion - After Replacement

Administer oxytocin to help the uterus contract and antibiotics to prevent infection.

Nursing Care for Uterine Inversion

Monitor vital signs and bleeding, maintain IV fluids and oxygen, provide comfort and reassurance, administer medications, and document everything.

Complications of Uterine Inversion

Severe postpartum hemorrhage, hypovolemic shock, infection (endometritis), recurrent inversion, and rare infertility or uterine damage.

Prevention of Uterine Inversion

Proper third-stage management, wait for placental separation signs before cord traction, avoid fundal pressure before contraction, use oxytocin appropriately, and educate staff.

Disseminated Intravascular Coagulation (DIC)

An acquired disorder of blood clotting where the fibrinogen level falls below normal limits.

Classification of DIC - Acute DIC

Sudden and severe form, common in pregnancy complications.

Classification of DIC - Chronic DIC

Develops slowly, often in conditions like cancer.

Etiology of DIC in Obstetrics

Placental abruption, amniotic fluid embolism, retained dead fetus, septic abortion, infection, and severe preeclampsia or eclampsia.

Risk Factors for DIC

Pregnancy complications, infection, or severe tissue injury.

Clinical Manifestations of DIC - Early Signs

Early bruising, oozing at IV sites, and bleeding gums.

Clinical Manifestations of DIC - Progressive Signs

Petechiae, ecchymosis (skin bleeding), and bleeding from nose, vagina, or surgical wounds.

Clinical Manifestations of DIC - Severe Signs

Hypotension, tachycardia, pallor, shortness of breath, and signs of shock or organ failure.

Diagnostic Evaluation for DIC - Platelet Count

Low, indicating platelets are being consumed.

Diagnostic Evaluation for DIC - Prothrombin Time (PT)

High, indicating slow clot formation.

Diagnostic Evaluation for DIC - Thrombin Time (TT)

High, indicating delayed fibrin formation.

Diagnostic Evaluation for DIC - Fibrinogen

Low, as it is used up in widespread clotting.

Diagnostic Evaluation for DIC - Fibrin Split Products

High, indicating that clots are being broken down.

Diagnostic Evaluation for DIC - D-dimer

High, confirming that fibrin breakdown is occurring.

Therapeutic Management for DIC

Identify and treat the underlying cause (e.g., deliver fetus, control infection); medical therapy includes IV heparin, blood replacement, cryoprecipitate, or fresh-frozen plasma.

Goal of DIC Management

To stop the triggering event and allow the body's normal clotting mechanisms to recover.

Nursing Care for DIC

Monitor vital signs, maintain IV/oxygen, monitor bleeding sites, prepare for transfusions, and provide emotional support.

Complications of DIC - Short-Term

Massive hemorrhage, hypovolemic shock, and acute kidney injury.

Complications of DIC - Long-Term

Organ damage from poor perfusion and possible maternal death.

Prevention of DIC

Prompt management of pregnancy complications, avoiding retained products of conception, monitoring at-risk patients, and ensuring safe delivery practices and infection control.

Subinvolution

A condition where the uterus does not shrink back to its pre-pregnancy size within the expected postpartum timeframe.

Classification of Subinvolution - Primary

Occurs without infection; includes Myogenic (weak muscles), Microcirculatory (impaired blood flow), and Endocrine (hormonal/breastfeeding issues) types.